342701315-12-15-2023-27-AS-AVIA-CYJLDH-20231215073954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701315
Report Date: 12/14/2023
Date Signed: 12/15/2023 07:41:18 AM

Document Has Been Signed on 12/15/2023 07:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	QUINLEY SENIOR CARE		FACILITY NUMBER:	342701315
ADMINISTRATOR:	CARPIO, KATHERINE		FACILITY TYPE:	740
ADDRESS:	8712 VIA ALTA WAY		TELEPHONE:	(916) 594-5353
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 4		CENSUS: 0	DATE:	12/14/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Delia Quinley and Kathrine Caprio		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/14/23, at 10am, Licensing Program Analyst (LPA), Arvin Villanueva conducted an announced inspection to the above facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 6/29/23, for an Initial license for a Residential Care for the Elderly. The requested capacity is for 4 residents. LPA was greeted and accompanied on inspection by the licensee, Delia Quinley and facility administrator, Kathrine Caprio. Facility is a single-story house. Facility has 3 resident bedrooms (room #2, #3 and #4 on the facility sketch), 1 staff room (room #1), 2 resident bathrooms, living room/dining room and kitchen. The resident bedrooms are spacious and will easily accommodate the resident's furnishings. There is a shaded outdoor area equipped with a table and chairs. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents' Bedrooms: LPA observed 3 resident bedrooms. Rooms #1, #2, and #3 are fire cleared for ambulatory residents only. Room #4 is fire cleared for 2 non-ambulatory residents. Bedroom #4 has two beds, two chairs, two nightstands, overhead lighting, closet and two dressers with several drawers. Bedrooms #2 and #3 have one bed, one chair, one-night stand, overhead lighting, closet or wardrobe and a dresser with several drawers. All drawers comply with the requirement of 8 cubic feet of space and there was ample closet space. {Con't on LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: QUINLEY SENIOR CARE	FACILITY NUMBER: 342701315
	VISIT DATE: 12/14/2023

NARRATIVE

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Bathroom: Facility has 2 resident bathrooms. One of the bathrooms is located in bedroom #4. All bathrooms have working toilets, wash basins and full baths have showers. Both bathrooms are equipped with non-skid mats and close-lid garbage. LPA observed licensee install a commode over the toilet in the bathroom located in bedroom #4. LPA provided technical assistance to install additional grab bars in the bathrooms. LPA observed adequate lighting in hallway leading to bathrooms via nightlights.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen and hygiene supplies stored in linen closet, which is at end of the hall between the bedrooms.

Emergency Phone Numbers, Exit Plan & Menu: The facility has a landline which was called by LPA and is operational. Emergency Disaster Plan posted & readily available for review on the wall. One fully charged fire extinguisher were found in hallway located between the family room and living room. Fire extinguisher was purchased on 7/21/23.

Toxins: Toxins locked/stored under kitchen sink and in the garage and are inaccessible to residents.

Water temperature: Water temperature in kitchen and bathrooms measured between 111 degrees F and 116 degrees F.

Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in locked drawers. Food supply was adequate and stored in kitchen refrigerator and cabinets.

Smoke Detectors and carbon monoxide: A total of seven (7) smoke detectors located in the livingroom, kitchen area, hallway and in each bedrooms and one carbon monoxide detector located in the hallway going to the bedrooms. One smoke detector and carbon monoxide were tested and are fully operational.

{Con't to LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: QUINLEY SENIOR CARE	FACILITY NUMBER: 342701315
	VISIT DATE: 12/14/2023

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Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage. Washer and dryer are located in the garage.

Medications, First-Aid Kit & Book: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet in the kitchen area, available for staff use but inaccessible to residents.

Residents & Staff Files: Applicant will not be handling cash resources of residents at this time but will submit necessary documents for any changes. Records of staff and residents shall be stored in a locked kitchen cabinet accessible to staff.

Reading Material, Games, Equipment & Materials: The facility has games and reading materials at this time but will be purchasing more activity materials in the future. Outside activity area is properly enclosed.

Pool/Jacuzzi & Pets: LPA did not observe any pets or bodies of water at the facility.

Component III: Conducted at the Pre-Licensing visit, on 12/14/23 at Quinley Senior Care, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted with Delia Quinley and Kathrine Caprio, and a copy of this report was provided. Accordingly, LPA Villanueva will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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